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Anaesthesia, 2010, 65 (Suppl. 1), pages 76–83 doi:10.1111/j.1365-2044.2009.06203.

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Trunk blocks for abdominal surgery


O. Finnerty,1 J. Carney2 and J. G. McDonnell3
1 Specialist Registrar, 2 Registrar, Department of Anaesthesia, Clinical Sciences Institute, National University of Ireland,
Galway, Ireland
3 Consultant, Department of Anaesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland

Summary
In this review, we discuss the central non-neuraxial regional anaesthesia blocks of the abdomen,
including intercostal and intrapleural blocks, rectus sheath and ilioinguinal-iliohypogastric blocks,
transversus abdominis plane blocks and paravertebral blocks.
. ......................................................................................................
Correspondence to: Dr John McDonnell
E-mail: johngmcdonnell@gmail.com

The inability to provide safe, reproducible analgesia after surgery. Unfortunately, it is not always possible or
abdominal surgery remains one of the impediments to the appropriate to provide epidural-based analgesia to this
introduction of regional anaesthesia techniques for this patient population. The shift towards short-stay surgery,
surgical population. The abdominal wall is supplied by the the introduction of fast-track surgery protocols, the
lower six thoracic and upper two lumbar sensory nerves, general unavailability of monitored beds and the incidence
either through extensions of the intercostal branches or, of sepsis or a bleeding diathesis has resulted in patients,
for the more caudal nerves, through the musculature of being denied a central neuraxial mode of analgesia. There
the abdominal wall. These nerves pass through a number is thus the need for reliable alternatives to intrathecal and
of plexuses and there is therefore a variation in the course epidural-based analgesia for abdominal surgery.
of individual nerves from one patient to another [1]. As a
result, the use of anatomical knowledge to achieve
Intercostal and intrapleural blocks
analgesia after abdominal surgery and the evolution of
approaches over time have resulted in a variety of analgesic The intercostal nerve block is aimed at the ventral rami of
techniques there are used in current clinical practice. the sensory nerve that runs in the small neurovascular
The extensive origin of the nerves that must be blocked bundle at the inferior aspect of each rib (Fig. 1). The
to provide analgesia for large abdominal incisions poses dorsal rami supply sensation to the musculature and skin
significant problems in the search for suitable regional of the middle back. This block is recognised for its
anaesthesia techniques. Limited operative fields are much analgesic role in rib fractures and thoracotomy, and also in
more amenable to regional techniques. Technological upper abdominal procedures such as open cholecystec-
advances, such as real-time ultrasonography, allow more tomy [3, 4]. As a single block, the duration of action is
accurate identification of plexuses and peripheral nerves, limited, and repeated injection or continuous infusion
with a corresponding improvement in block success [2]. As should be considered, depending on the duration of
a result, there is a better appreciation of individual anatomy. analgesia required [5]. There is no described fascial sheath
These advances also allow the anaesthetist to perform around the intercostal nerve branches and the deposition
blocks more distally, e.g. in the abdominal field. Although of local anaesthetic (LA) solution in close proximity is
regional anaesthesia is not the only change in managing sufficient to block the nerve. The natural defects in the
these patients, the introduction of new techniques or new intercostal muscle, that allow spread of LA solution to the
approaches to old techniques has resulted in ever-increas- nerve, also allow it to spread around the internal aspect of
ing numbers of patients who receive non-central neuraxial the ribs to reach the intercostal spaces above and below
blockade for abdominal surgery, and warrants discussion. [6, 7]. Therefore, the sensory block can extend beyond
The low thoracic epidural remains the ‘gold standard’ the injection site, although clinical use of this has not
for the delivery of postoperative analgesia after abdominal been documented and multiple level injections should

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76 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 76–83 O. Finnerty et al. Æ Trunk blocks
. ....................................................................................................................................................................................................................

Figure 2 Interpleural nerve block.

For an intrapleural block, LA is deposited between the


visceral and parietal layers of the pleura (Fig. 2). It has
been shown to be an effective method of achieving
analgesia for subcostal and flank incisions [16–18]. A
recent review of 11 studies that used intrapleural catheters
Figure 1 Intercostal nerve block. for analgesia after open cholecystectomy demonstrated
significant decreases in pain and opioid requirements [19].
continue to be used. Catheters placed into the intercostal Studies have shown that when total intravenous anaes-
space also provide access to the paravertebral region and thesia and intrapleural analgesia are used for laparoscopic
there is overlap between the two techniques [8]. surgery, pain scores are improved and there is no demand
Study of the pharmacokinetics of bupivacaine in for supplemental analgesia in the postoperative period [20,
intercostal nerve blockade in children has shown that 21]. This strategy has been used for analgesia after
these blocks are safe, but the absorption of LA is faster and nephrectomy with varying degrees of success [22, 23].
the volume of distribution and the clearance are greater It has been suggested that the reason for failure of
when compared with adults [9, 10]. Local anaesthetic reliable analgesia from intrapleural block is surgical
mixed with contrast medium injected into the intercostal interruption of the continuum of the pleura or the loss
space spreads centrally and medially within 30 s, and of LA solution through chest drains. Furthermore, this
almost complete absorption occurs within 11 min. This technique has been shown to be associated with an
explains the rapid peak plasma LA concentration achieved increased risk of pneumothorax [18]. The most recogni-
with this block. Sensory blockade can be prolonged by sed complications of intercostal blocks include rapid
the use of a catheter and is effective after open cholecys- systemic uptake or haemopneumothorax. Dravid et al.
tectomy [11]. Giving top-ups via intercostal catheters [19] have estimated the incidence of pneumothorax at 2%
improves respiratory function, and 92% of open chole- in their recent review. Intrathecal injection through an
cystectomy patients in one study required no further intercostal block has been described and was attributed to
analgesia in the first 24 h after surgery [11]. This analgesic extension of the block solution into the dural sac [24].
effect was also seen with laparoscopic cholecystectomy
[12]. When blocks of the tenth to twelfth thoracic nerves
Rectus sheath block
(T10–T12) were performed, opioid requirements and
visual analogue pain scores were significantly decreased The rectus sheath block (Fig. 3) was first introduced into
[13]. The intercostal approach is also successful in the clinical practice in 1899 when it was used to achieve peri-
management of pain after orthotopic liver transplant. operative muscle relaxation and as an analgesic adjunct. In
While there was delayed elimination of both enantiomers the modern setting, the block has been shown to decrease
of bupivacaine, there was no accumulation, even after opioid requirements after both diagnostic and interven-
repeat dosing [14]. In a study of paediatric liver tional laparoscopy [25, 26]. In a case report, a rectus
transplants, more than half the children required no sheath block was used as the sole anaesthetic technique for
further analgesia and, in those that did, the use of a block an umbilical hernia repair in an obese patient unsuitable
resulted in significantly lower opioid requirements [15]. for central neuraxial anaesthesia and deemed too high-risk

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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 77
O. Finnerty et al. Æ Trunk blocks Anaesthesia, 2010, 65 (Suppl. 1), pages 76–83
. ....................................................................................................................................................................................................................

Figure 3 Rectus sheath block.

for general anaesthesia. Despite the patient’s obesity, the


landmarks were easily identifiable and no other analgesia
was required [27].
It is important to perform bilateral blocks in the Figure 4 Ilioinguinal-iliohypogastric nerve block.
abdomen and to use large volumes of LA solution [28,
29]. The rectus sheath block is suited to incisions about
the midline and has been shown to have beneficial variation and the operator’s not knowing the exact
analgesic qualities after laparotomy [30]. It can be position of the needle tip [40]. The introduction of
combined with other blocks, such as the ilio-inguinal ultrasound has led to increased success rates and has
block, to achieve wider blockade for transverse incisions allowed for optimisation of LA doses [41, 42]. When this
below the umbilicus. However, better analgesia was block was performed using landmark techniques, only
obtained when the incision was limited to the midline. 14% of the LA solution was correctly placed about the
The existence of myofascial insertion points on the nerves; the remaining 86% was administered into
anterior border of the rectus muscle limits the spread of surrounding muscular structures [42].
LA solution anteriorly. Posteriorly, the facial sheath is
absent inferior to the arcuate line and, if the peritoneum is
Transversus abdominis plane block
inadvertently pierced, bowel perforation may occur. The
use of ultrasound for the performance of this block aids The transversus abdominis plane (TAP) block provides
the placement of catheters to facilitate extended post- effective analgesia when used as part of a multimodal
operative analgesia [29]. analgesic regimen for a variety of abdominal procedures.
Local anaesthetic is deposited into the neurofascial plane
between the internal oblique and transversus abdominis
Ilio-inguinal and iliohypogastric blocks
muscles (Fig. 5). It was described recently [43, 44] and its
Ilio-inguinal and iliohypogastric blocks (Fig. 4) have been clinical applications are still being investigated and
used extensively for analgesia for procedures below the developed. Within the TAP run the afferents of T6 –
umbilicus, mostly commonly for inguinal hernia repair, L1 that provide sensation to the anterior and lateral
orchidopexy, varicocoele or hydrocoele repair and for abdominal wall [45]. These nerves can be traced from the
obstetric or gynaecological surgery. The block has a anterior rami in the intervertebral foramina and either pass
proven safety record in children [31, 32] and provides through the intercostal spaces before perforating the
analgesia comparable with caudal analgesia for day-case abdominal wall in the TAP, or run over the internal
procedures [33]. It has been used successfully with surface of the quadratus lumborum muscle before enter-
sedation for repair of inguinal hernias in adults and ing the TAP; they then form the plexuses or directly
provides comparable anaesthesia and analgesia to spinal supply the superficial musculature and skin of the anterior
anaesthesia [34, 35]. When combined with general abdominal wall [1]. The first description of the block used
anaesthesia, patients require significantly less postopera- a loss-of-resistance technique with a wide-bevel regional
tive opioid and can restart an oral diet and mobilise anaesthesia needle in the lumbar triangle of Petit, situated
sooner [36]. The block has been successful in providing above the iliac crest posterior to the midaxillary line [44].
analgesia and a significant decrease in opioid requirement Cadaveric and radiological studies demonstrated the
after obstetric and gynaecological surgery [37–39]. The deposition of LA in the plane [43]. Randomised
reported success rate with this block remains variable even controlled trials using TAP blocks as part of a multimodal
in experienced hands, most probably due to anatomical postoperative analgesic strategy show a significant

 2010 The Authors


78 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 76–83 O. Finnerty et al. Æ Trunk blocks
. ....................................................................................................................................................................................................................

TN

ULTRASOUND
PROBE

ST
TA - Transversus abdonminus
IO - Internal oblique
EO - External oblique
TN - Touhy needle
ST - Subcutaneous tissue
Skin QL - Quadtratus lumborum
LD - Lattisiums dorsi
IL - Longissius, Iliocostalis
LS - Lumbar spine
PM - Psoas muscle

Figure 6 Ultrasound-guided transversus abdominis plane (TAP)


block.
Figure 5 The lumbar triangle of Petit – the site of injection of
the transversus abdominis plane (TAP) block. directly to the area of surgery. The duration and efficacy
of this approach vs the loss-of-resistance technique
reduction of visual analogue scale pain scores and remains to be demonstrated in a randomised, controlled
a significant decrease in morphine consumption after trial [55].
Pfannenstiel incisions for caesarean section and total There is discussion as to both the dermatomal extent of
abdominal hysterectomy, and midline incisions for lapa- the TAP block and its indications. The quality of
rotomy [46, 47]. There are case series reporting its use for analgesia of the TAP block has not been compared with
open retropubic prostatectomy [48] and unilateral surgery other peripheral or central nerve blocks. The exact site of
such as appendectomy, hernia repair and orchidopexy action of the block is not fully elucidated; does it block
(Carney 2008, unpublished data). The technique’s success somatic nerves alone or does it also ascend posteriorly and
is due in part to the variation in the distal course of cephalad to block autonomic nerves? The block described
abdominal nerves and the possibility that a more proximal by McDonnell et al. has been shown to have a combi-
injection may provide a broader sensory block. nation of local and more distant action. There is
With increasing use of ultrasound in clinical anaesthetic radiological evidence of spread of LA and contrast on
practice, there have been descriptions of its use for TAP magnetic resonance imaging (MRI) and computerised
block and for the insertion catheters to provide contin- tomography (CT) beyond the TAP to the quadratus
uous analgesia [49–52]. A repeat of the cadaveric block lumborum and to intrathoracic paravertebral regions
with an ultrasound technique in the posterolateral [56]. McDonnell et al. describe a TAP block in volun-
abdominal wall demonstrated deposition of injectate in teers to the T7 dermatome. A randomised, controlled trial
the TAP and bathing of the T10 – L1 nerves [53]. There of midline laparotomy for large bowel surgery showed a
is recognition of in vivo variations between individuals significant analgesic effect when the incision was cephalad
identified by ultrasound, and a recent cadaveric study to to the umbilicus [47]. Hebbard and Shibata et al. contest
classify the triangle of Petit remarked on its absence in the frequency of paraesthesia cephalad to the umbilicus in
17% of individuals [54]. This would suggest a role for their case series [55, 57]. However, the technique used by
ultrasound in the TAP block (Fig. 6). There are two both Hebbard and Shibata et al. was not the same as the
general approaches when using the ultrasound technique. original description. Research on the block continues and
The first is to identify the TAP in the anterior abdominal the indications continue to expand [50, 57, 58].
wall and commence the block from medial to lateral. The As it is still in development, there is a natural
second is to identify the TAP and attempt to replicate the exploration of the utility of the TAP block as a ‘rescue’
deposition of LA much more laterally, as would be done block of last resort and, in the authors’ personal experi-
with a loss-of-resistance landmark technique. The first, ence, it is frequently used when unexpected surgery
anterior subcostal approach, as outlined by Hebbard, involves a patient unsuitable for epidural analgesia due to
suggests a potential use for upper abdominal incisions institutional or individual patient reasons [58, 59]. In
such as cholecystectomy since the muscles are well particular, in instances in which opioid analgesia has been
defined. In performing this block, LA is deposited insufficient to bridge the gap between excessive side
incrementally in the TAP and the needle is advanced effects and analgesia, performing a TAP block has

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Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland 79
O. Finnerty et al. Æ Trunk blocks Anaesthesia, 2010, 65 (Suppl. 1), pages 76–83
. ....................................................................................................................................................................................................................

produced an effect within minutes, with the full benefit


occuring within 1 h.
If the block has multiple sites and modes of action, this
might explain why there is such a variation in the degree
of block with time. Initial studies of its use for chronic
abdominal pain have shown that there may be a role for
this block as either a diagnostic or a therapeutic tool, in
particular for chronic wound pain or neuralgia associated
with scar formation.
There is one case report of a complication following a
TAP block, in which it is assumed that inadvertent
advancement of a blunt regional anaesthesia needle
beyond the TAP and transversus abdominis muscle into
the liver resulted in intraperitoneal haemorrhage [60]. As
it is an invasive procedure, the usual complications of
tissue damage, haematoma and infection are to be
expected, although the incidence has yet to be deter- Figure 7 Paravertebral block.
mined. Conceptually, the block is a compartmental block
and therefore involves injection of LA at a volume of
0.3 ml.kg)1 or greater. Even at a dilute concentration, LA of analgesia is not significantly longer than that produced
in such large volumes can have serious consequences if by a field block. The block, a multiple injection
injected intravascularly or if there is rapid uptake by the technique, takes < 15 min to perform and the average
tissue into which it is injected. The pharmacokinetics of onset of surgical anaesthesia occurs in < 30 min. The
LA used in this block is an area of current investigation, mean duration of analgesia is 14–15 h, but with a wide
but are likely to be similar to those of ilio-inguinal and variation [63–65]. The identified complications include
iliohypogastric blocks as they are anatomically similar. epidural spread (0.05–0.14%) and block failure (0.06–
In summary, the TAP block is becoming more widely 0.09%). Despite the success of the block for inguinal
used and has a role in managing postoperative pain as part hernia surgery, debate still exists with regard to the
of a multimodal analgesic strategy. Further characterisa- optimal peripheral block for this ambulatory surgery [66,
tion of the block with the use of ultrasound will continue 67].
due to its recognised utility. Naja et al. used a nerve stimulator technique to identify
the paravertebral space and compared their block with
systemic analgesia and with ilio-inguinal nerve block in
Paravertebral block
children undergoing inguinal hernia repair. Use of the
The paravertebral block has been used extensively for paravertebral block provided significantly lower pain
anaesthesia and analgesia for abdominal surgery, especially scores, less systemic analgesia consumption, greater
for ambulatory inguinal hernia repair. The injection of parental satisfaction and higher rates of same-day dis-
LA into the paravertebral space (Fig. 7) provides mainly charge. Furthermore, there was greater intra-operative
unilateral anaesthesia and analgesia, avoids the severe haemodynamic stability and significantly lower pain
autonomic dysfunction seen with neuraxial techniques scores and analgesic consumption compared with blind
and allows the patient to mobilise earlier. It has been used ilio-inguinal nerve block. Parental and surgical satisfaction
extensively both as a sole anaesthetic technique, in was greater with the paravertebral technique. There were
inguinal hernia repair and breast surgery, and to comple- no complications in the paravertebral group other than
ment general anaesthesia for a variety of surgical proce- localised tenderness, but a small number of children had a
dures. transient femoral nerve block after the ilio-inguinal nerve
The paravertebral approach to analgesia after inguinal block [68, 69].
herniorrhaphy can provide analgesia that is superior to Paravertebral blocks have been used less frequently
oral analgesia, local field blocks and cryo-analgesia [61, for other abdominal procedures. Richardson et al. [70]
62]. Paravertebral blockade can also improve the effi- reported a series of eight patients undergoing abdominal
ciency of recovery room usage, decrease the times to vascular surgical procedures. Bilateral paravertebral
ambulation and recommencement of oral intake, decrease blocks with catheters at T10 were sited after induction
postoperative nausea and vomiting, and result in earlier of general anaesthesia and their use continued for 4 days
discharge from hospital [64–66]. However, the duration after surgery. Additional analgesia comprised diclofenac

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80 Journal compilation  2010 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2010, 65 (Suppl. 1), pages 76–83 O. Finnerty et al. Æ Trunk blocks
. ....................................................................................................................................................................................................................

and patient-controlled analgesia with morphine. Car- Conflicts of interest


diovascular stability was noted upon incision, clamping
The authors are all involved in research in various
of the aorta and throughout surgery in all patients. No
regional anaesthesia techniques and have published
further intra-operative opioids or neuromuscular block-
extensive work on the TAP block using the landmark
ing drugs were required and postoperative analgesia was
technique. No conflict of interest is identified. Likewise,
excellent. There were no complications attributed to
no author has received sponsorship, fiscal or other reward
the paravertebral blockade. Bilateral paravertebral blocks
in the compilation of this paper.
and sedation for ventral hernia repair gave lower pain
scores, shorter hospital stays and significantly lower
opioid requirements, nausea or vomiting when com- References
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